PNP 1 Management Exam #2

First 28 days of extrauterine life

-Improve maternal health and pregnancy outcomes
-Reduce disability rates in infants
-Improve the health and well-being of women, newborns and families in the U.S.

-Reducing health of pregnant women
-Reducing birth defect rates
-Decreasing newborn deaths
-Addressing maternal and newborn death risk factors
-Increasing breastfeeding rates
-Obtain recommended universal screening panel (RUSP) for state mandated diseases
-Reducing the proportion of children with a metabolic disorder who experience developemental delay
-Increase the percentage of healthy full-term newborns who are placed to sleep on back

-Prenatal screening for Rh(D) incompatibility, HIV, Hep B, Syphilis, Chlamydia, and Gonorrhea
-Promote breastfeeding
-Screening neonates for sickle hemoglobinopathies to identify newborns who may benefit from antibiotic prophylaxis to prevent sepsis
-Screening for congenital hypothyroidism for all newbowns within the first 4 days of life
-Screeening for phenylketonuria (PKU) for all newborns before discharge from the nursery. Newborns who are tested before they are 24 hours old should receive a repeat screening test by 2 weeks old
-Topical ocular prophylaxis of all newborns to prevent ophthalmia neonatorum
-Screening for developmental hip dysplasia

-Provides metabolic functions for the fetus
-Oxygenated blood from the placenta arrives to the fetus through the umbilical vein

-High fetal pulmonary vascular pressure
-Blood is shunted from the right to the left side of the fetus' heart through the foramen ovale
-Or to the systemic ciculation through the ductus arteriosus

-Once the cord is clamped, the newborn simultaneously begins to breathe and the high pulmonary vascular pressure drops
-Allows blood to flow to the lungs for oxygenation
-Foramen ovale and ductus arterious are no longer needed and close
-GI tract begins to absorb nutrients and excreting waste
-Renal system excreates waste and mantains a chemical balance
-Liver metabolizes and excretes toxins
-Immune system begins protecting against pathogens

Sympathetic system changes:
-Tachycardia
-Rapid respirations
-Transient rales
-Grunting
-Flaring and retractions
-Falling body temperature
-Hypertonus
-Alertness
Paraympathetic system changes:
-Initiation of bowel sounds
-Production of oral mucus

-Begins after an interval of sleep
-Oral mucus production
-Heart rate becomes more labile
-Newborn becomes more responsive to endogenous and exogenous stimuli
-Meconium is passed

-Past maternal history
-Past obstertic history:
Number of previous pregnancies (number of born alive and stillborn)
Number of elective or spontaneous abortions
Number of preterm and term deliveries
C-section and indications for them
Health status of living children (if deceased, age and cause of death)
-Family history
-3 generation pedigree: focus on genetic conditions, congential defects/diseases, intellectual disability, or other diseases/conditions (HTN, hyperlipidemia, heart disease or familial cancers)
Age and health status of living relatives
Causes of death of family members

-Obstertric history
Current maternal health, including depression or other mental health conditions
Maternal age
Prenatal care (duration of)
Medications used during preganancy (prescrioption, OTC, and natural health products)
Use of preganancy-enhancing drugs or technology
Infections (group B strep) and illnesses during pregnancy
Alcohol, tobacco, and other drugs used during preganancy
Environmental exposures to heavy metals (mercury or lead) or bacteria (Listeria)
HTN or glucose intolerance
Duration of labor, duration of ruptured membranes, analgesia, anesthesia, presentation and route of delivery, use of forceps or vaccum assit
Polyhyramnios (exessive fluid) or oligohydramnios (reduced fluid)
Stained meconium or foul-smelling amniotic fluid
Fever

-Social history
Emotional stressors during preganancy (homelessness or partner abuse)
Unplanned or unwanted pregnancy
Financial and emotional support
Dietary restrictions (vegan)
Educational background of parents
Partner's anticipated involvement in childrearing
Ages of other children in the home

**Important**
-Maternal age, gravida, para
-Maternal Blood group & Rh factor
-Historic duration of pregnancy (# weeks) (make sure it matches up)
-Prenatal conditions/complications
-Intrapartal Complications
-Medications used during labor (mag=sleepy baby)

-Delivery anesthesia
-Delivery date & time
-Type of delivery & rationale
-Hours of ROM before delivery (prolonged = spesis risk)
-Length of Labor (>24hr & <6 hrs-fetal stress because lungs aren't being squeezed out)
-GBS status
-Birth weight
-APGAR score

-1 minute
-5 minutes

-Healthy infant
-Vigorous, pink and crying
-Requires only warming, drying and gental stimulation
-Occasionally requires oxygen for a short period

-Moderately depressed infant
-NICU
-Cyanotic
-Slow, irregular respirations
-Good muscle tone and reflexes

-Severely depressed infant
-NICU
-Limp, pale or blue
-Apneic, slow heart rate
-Maximal resucitative efforts with bag and mask, chest compressions, IV volume expansion and drug therapy

-5-minute APGAR score is an indication of how well the resuscitation efforts have succeeded
-Caution must be used when using APGAR score to predict long-term mortality and developmental outcomes
-Useful in determinging long-term health outcomes only when combined with other factors such as:
Fetal status
Umbilical cord or scalp blood pH
Evidence of organ injury
Seizures

-Term (39-42 weeks)
-Pre-term (<39weeks)
-Post-term (>42weeks)

-Within 2 hours
-Based on physical exam to confirm maternal estimated dates

10th to 90th percentiles

-<10 percentile
-Head may be microcephalic
-Head circumference: <5th percentile
-Head circumference is the first to usually show catch up growth followed by weight and then length

Due to intrinsic fetal conditions:
-Chromosomal abnormalities

-Due to impaired placental perfussion
-Nutrient deprivation during fetal development

-Restricted fetal weight, length or head circumference due to pathophysiologic process in utero
-Not necessarily SGA because IUGR infant may be below expected weight but not below 10th percentile for age

-HTN
-DM (poorly controlled)
-Autoimmune disease
-Cardiac or respiratory disease
-Maternal infection

-Abnormal cord insertion or cord abnormalities
-Abnormal placentation
-Placental abruption

-Multiple gestations
-Chromosomal abnormalities
-Fetal infection

->90th percentile
-May be a result from fetal factors (genetic or chromosomal) or maternal factors (obesity or DM)

-Birth trauma
-Neonatal asphyxia
-Hypoglycemia
-Polycythemia
-Hyperbiliruminemia

Weight below 2500g

Weight below 1500g

Weight below 1000g

-Maternal age less than 16 or greater than 35 years of age
-Race and ethnicity
-Materanl chronic health conditions
-Maternal medications
-Nutritional status
-Environmental toxins or occupational chemical toxins
-Access to prenatal care

-Alcoholism
-Tobacco use
-Illicit drug use
-OTC drug use

-Measurements normally include: weight, length, and occipitofrontal head circumference (OFC)
-Abdominal and chest circumference is not typically included unless there is clinical concern

Measured as heel to crown with infant lying on a flat surface

-Measured with tape just above the brow line to the occipital prominence
-Transient head molding or overlapping of the cranial bones may impact this measurement

-Obtained using a standardized scale
-Unclothed or standadized measurement of diaper
-Newborns can lose 10% of their birth weight in the first 72 hours due to contraction of the extracellular space

Infants and up to 2 years of age

-32-38 cm
-Head approaches half the total body length

44-55 cm

2500-3900 g

-30-36 cm
-1-3 cm less than OFC

-32 to 36 weeks gestation = to OFC
-After 36 weeks gestation, >OFC

-Heat loss of a newborn is 4x of an adult
-Avoid cool drafty environments
-Towel dry the newborn after brith to prevent evaporative heat loss and place skin to skin with mother is newborn is stable
-Use a radiant warmer and wrap in warm blanket and cover the head to reduce heat loss

-Squeezing action on the chest during a vaginal delivery assists in the expulsion of amniotic fluid from the lungs
-Further expulsion of amnuotic fluid from the lungs happens during the first few deep breaths
-C-section does not give the squeezing action, so increased respiratory effort and adequate bulb suction is necessary
-Bronchovesicular aor bronchial breath sounds are normal at birth
-Fine crackles are also normal during the first few hours of life

-2 arteries
-1 vein

Associated with congenital anomalies (cardiac and renal)

-30 to 60 seconds following birth
-Improved iron stores to prevent anemia
-In preterm newborns: decreased the risk of intracerebral hemorrhage and necrotizing enterocolitis
-Decreased blood cord volume available for banking if families are interested in this

-Well-lit room
-Done while the infant is calm
-Ensure you have warm hands and equipment
-Weighed on appropriate calibrated scale
-Length is on a firm surface
-Percussion and transillumination can be used to assess certain organs (percussion for liver) (transillumination for hydrocele)

-Inspection
-Auscultation
-Palpation

-Begin the exam in the least disruptive manner
-Should be done in a systemic approach to ensure no areas are missed

-Overall size, shape, & symmetry
-Activity State:
Quiet sleep
Active sleep
Drowsy
Alert
Fussy
Crying
-Posture, tone
-Skin color, signs of trauma

-Respiratory effort (the more signs the more concerning)
Grunting
Nasal flaring
Retractions
Respiratory Rate
-Jitteriness (some small jitters are normal)
No abnormal gaze or eye movements
Stimulus sensitive
Predominant motion is tremor-not clonic jerking

-All states in the US require newborn screenings
-Screens for a variety of genetic, metabolic disorders and selected congenital abnormalities
-Done at 24 hours or before discharge
-If done before 24 hours, rescreening should be done by 14 days years old

-Recommended by 1 month old
-Newborns born at a low birth weight, rubella or other infections, malformation, trauma, asphyxia, prematurity, NICU stay, or antibiotics have a higher risk of hearing problems
-Otoacoustic emissions (OAE) or auditory brainstem response (ABS)

-Antibiotic eye ointment: prophylaxis for ophthalmia neonatorum
-Vitamin K injection: prevention of classic and late onset hemorrhagic disease

-Bright Futures guidelines recommend leaving the cord to air dry and placing the diaper below the cord until it separates.
-Alcohol is not recommended
-Cord separation can take up to 10 to 14 days, after which a slight bloody discharge may follow for another one to two days
-Babies should not be submerged for bath time until the cord falls off, until that time they should be sponge bathed
-Avoid bellybands or coins placed on the naval to prevent or decrease umbilical hernias due to the risk of infection
**If a foul-smelling discharge or rapidly expanding erythema is noticed around the umbilicus, parents should be educated to bring back the baby immediately to be evaluated for possible sepsis**

-Scar tissue around the umbilical cord
-Silver nitrate treatment

CONCERNING
-Infection of the umbilical cord
-Discharge and erythema

-No evidence for routine circumcision but that the benefits of the procedure outweigh the risks
-Decision is up to the parents
The skin normally adheres to the penis and cannot be retracted at birth but will gradually loosen as the baby grows
-Parents should be instructed never to force the foreskin back

-If the baby is circumcised, the penis should be cleaned every day with cotton balls dipped in tap water and then followed by the placement of a small amount of petroleum jelly to the tip of the penis.
-This should be done for the first two to three days after the circumcision to prevent the penis from sticking to the diaper.
-Some parents also prefer to rub a small amount of petroleum jelly onto the inside of the diaper, facing the penis, which is fine.
-Both methods accomplish the same purpose, which is to allow for healing without causing further injury from the diaper. In the past, providers recommended that the penis be cleaned with soap and water but that is no longer recommended.

-Epi- or hydrospadias
-Ambiguous genitalia
-Familial bleeding disorders
-Exstrophy of the bladder
-Illness

-Do not require daily baths
-Use gentle cleansing agents
-Oils and lotions clog the skin pores and powders are a risk for lung inhalation.
-If moisturizers are needed for dry skin, brands that are highly recommended and appropriate for parents to use are Keri, Eucerin, Aveeno, and Cetaphil

-Review delivery and discharge summary for any follow-up needs
-Assess the newborn's heneral health, weight, hydration, and jaundice
-Identify any new problems
-Review feedings, stoolin, urination and consider lactation consultation if needed
-Assess quality of bonding
-Reinforce maternal and family education
-Review outstanding lab data
-Perform or repeat neonatal screen or other tests (bilirubin) if indicated
-Develop plan for healthcare maintenance, including emergency care, preventative care, immunizations and periodic screenings
-Evaluate mother for postpartum depression
-Refer to WIC if appropriate

-An immature infant's skin is thinner, friable and perable, and more easily disrupted
-Typically covered in vernix (cheesy-white odorless protective sebaceous secretion)
-Skin pigmentation varies with ethnic origin

Mucous membranes and tongue

NORMAL
-Bluish coloration of extremities that is present up to 24 hours
-Related to increased peripheral vascular resistance & results in sluggish circulation to hands & feet
-Make baby warmer and rewrap baby

CONCERNING
-Evident when less than 5g percent of desaturated hemoglobin is present
-Associated with etiologies such as cardiac or pulmonary disease, infection, metabolic and neurologic conditions, and hematologic issues (anemia or polycythemia)

-Pale or ashen appearance
-Due to poor perfusion, acidosis or anemia

-Ruddy appearance
-May indicate polycythemia

-Can be misleading
-Evident when there is 3-5g of desaturated hemaglobin
-Present in polycythemic infants with normal oxygen whereas its presence wtih anemia requires substantial hypoxemia and low oxygen content in the blood

-Bruises
-Evident over head and buttocks
-Usually associated to assistive devices such as forceps for delivery

NORMAL
-Type of hemangioma
-75% occur in the head
-May appear 1-2 months after birth & grow
-Usually stops growing by 8 months
-Most disappear by 7 years
-Treatment only if very large, location subjective to repeated trauma & bleeding, or growth after 8 months

-With strawberry mark
-Increases in size from 6-12 months and then shrinks with age
-Current treatments include laser therapy, high-dose steroids, & radiation
-Send to dermatology because of risk of compression on airway

NORMAL
-Lacy, red or blue vascular pattern appearing over most of the body surface
-Associated with low temperatures disappears when the newborn is warmed
-Persistence occurs with Downs and trisomy 18 syndromes

NORMAL
-Papular rash with possible vesicles-white halo around each lesion
-Commonly on trunk & diaper area
-“Flea bites”
-Transient
-Appears around day 1
-Disappears around day 7-10
-Eosinophils in smear from papule confirms diagnosis

NORMAL
-Clear, thin vesicles seen primarily over forehead, neck, or groin in the creases
-Result of obstructed sweat glands in humid environments

NORMAL
-Stork Bite
-Flat localized reddened areas common on upper eyelid, back of neck, occiput
-Darker when crying
-Capillary dilation
**Disappears when blanched**
-Usually fades by end of first year

-Nevus Flammeus
-Newly formed capillaries
-Does not resolve spontaneously
**Does not blanch with pressure**
-High-Fluence Modified Pulsed Dye Laser Photocoagulation With Dynamic Cooling most effective current treatment
-Can be associated with Weber Syndrome (neuro and eye complications)

NORMAL
-Vesicles that rupture easily leaving a halo of white scales
-Common sites: trunk, limbs, palms and soles
-Rarely lasts more than 2-3 days but can persist for 3 months

NORMAL
-Firm, pearly, white papules
-Disappear within the first few weeks of life
-Educate parents on not popping due to scarring and infection

NORMAL
-Irregular bruise-like spots
-Usually over buttocks & sacrum but can be more generalized
-Prevalent among African American, Asian, & some Europeans
-Usually fades in early school years
-Important to distinguish from abuse!

NORMAL
-Division of the body skin coloring from forehead to pubis into red and pale halves
-Occurs between days 2 to 5 but could be up to 3 weeks
-Transient and no treatment is indicated

-Yellowish, hairless smooth plaque on head and neck
-In adulthood they are complicated by basal cell carcinoma

CONCERNING
-Grouped vesicles on an erythematous base
-Diagnostics: Direct fluorescent antibody (DFA) or early enzyme-linked immunosorbent assays (ELISAs) detection of HSV antigens
-Management: Acyclovir

-Newborns have high RBC volume
-Bilirubin is a product of RBC hemolysis
-Bilirubin is a yellow-red pigment, causing skin discoloration
-Broken down & excreted by the liver
-Newborn liver is immature & not as effective in excreting bilirubin

-When serum bilirubin levels exceed 5 to 7 mg/dL
-Serum levels cannot be estimated by clinical examination

-Increased hemolysis
-Polycythemia
-Delayed cord clamping
Delayed rate of conjugation
-Abnormalities of excretion or absorption

-Hemolytic disease, anemia
-Inborn errors of metabolism
-Prematurity (35 to 36 weeks)
-Significant bruising or cephalohematoma
-Exclusive breastfeeding with significant weight loss or difficulty feeding

-Jaundice that develops within the first 24 hours
-The total bilirubin increasesn more than 5 mg/dL/24 hours, is more than 12.5 mg/dL before 48 hours old or the direct bilirubin exceeds 2 mg/dL
-Ethinic or geographic origin associated with hemolytic anemia (African or Mediterranean)
-Hepatobiliary disease
-Previous siblin requiring phototherapy

-Blood brain barrier is set at 5 days of life, if bilirubin is too high befiore then, it can get to the brain
-Bilirubin level of 25 to 30 mg/dL puts a newborn at risk and requires a blood transfusion
-Kernicterus (Bilirubin Encephalopathy):
Sensorineural hearing impairment
Cerebral Palsy
Ataxia
Seizures
Death

-Physiologic (affects 50-75% of all newborns)
-Pathologic
-Breast-Milk
-Breastfeeding

-Rises from 1 to 3 mg/dL to 5 to 6 mg/dL on the third day of life
-Declines to an adult level (<1.3 to 1.5 mg/dL) by day 10 to 12

Skin & whites of eyes look yellow

3 days

10-12 days

-Breakdown of excess RBC
-Immature newborn liver

-Breastfeed at least 8-12 times a day
-Check bilirubin level PRN
-Indirect sunlight

-Skin & sclera yellow
-Lethargy
-Poor feeds

-24 hours
-Huge red flag

-Rises quickly until treatment initiated-resolves with phototherapy
-Longer than 10-14 days

-Blood incompatibility
-Liver disease

-Medical evaluation
-Breastfeed or may need formula supplementation
-Phototherapy
-Blood transfusion

-Skin & sclera yellow
-Baby is:
Active
Alert
Nursing 8 times per day
Gaining weight
4 stools/day

-Early onset: 2 to 4 days
-Late onset: 7 days

-Peaks at 10 to 14 days
-Can remain elevated for 16 weeks

-Unknown
-Can be related to mother's milk

-Breastfeed at least 8-10 X’s/day
-Check bilirubin level regularly
-If level continues to rise after 14 days: phototherapy, rotate breast & formula, interrupt breastfeeding for 24hr

-Skin & sclera yellow
-Baby is:
Sleepy
Nursing < 8 times/day
Losing weight
Passing <4 stools/day

3 to 5 days

-Peaks at 3 to 5 days
-May continue to rise if baby continues to nurse poorly

-<8 nursings/day
-Mother-led feeding
-Poor breastmilk production, release or transfer

-Increase frequency or breastfeedings
-Baby-led feedings
-Look for signs of milk production, release and transfer
-Supplement if necessary

-Assess for jaundice in the first 24 hours
-Usually the face is impacted first, followed by the shoulders, chest, and abdomen
-Crude estimate of bilirubin level can be used to determine if a total serum bilirubin or transcutaneous bilirubin is necessary:
Face: 5 mg/dL
Mid-abdomen: 15 mg/dL
Soles: 20 mg/dL
-Petechiae, brusing, hepatosplenomegaly or signs of infections
-Lethargy, hypotonia, poor feedings, and loss of Moro reflex are signs of kernicterus
-Later signs of kerniterus are

-Lethargy
-Hypotonia
-Loss of Moro reflex
-Late signs:
Diminished tendon reflexes
Respiratory distress
Failure to suck
Opisthotonos
Bulging fontanalle
Twitching of face or limbs
Seizures
High pitched cry

Blood test performed on newborns to check for maternal antibodies that may be attacking the baby's red blood cells (RBCs)

-TcB (one-time mandatory screening before discharge)
-TSB (indirect or direct)
-Coombs test
-Venous ABO, Rh, blood type, isoimmune antibodies of the mother
-Hemoglobin
-Hematocrit
-Reticulocyte count

1. A TcB more than 70% of the recommended for phototherapy initiation
2. A TcB above the 75th percentile on the Bhutani nomogram
3. A TcB greater than 13 mg/dl at hospital followup
4. Currently under phototherapy

-This is the bilirubin created from red blood cell breakdown
-It then travels in the blood to the liver

-This is the bilirubin once it reaches the liver and undergoes a chemical change
-It moves to the intestines before being removed through your stool

-Physiologic Jaundice
-Breastfeeding Jaundice
-Congenital familial nonhemolytic jaundice

-Isoimmunization (ABO or Rh incompatibility)
-Abnormal red blood cell shape
-Red blood cell enzyme abnormalities

-Hepatitis
-Metabolic abnormalities
-Biliary atresia
-Cholesdochal cyst
-GI or pancreatic obstruction
-Sepsis
-Drugs

-Breastfeeding promotion and support
-Udentification hyperbilirubinemia risk factors
-Early and focused follow-up based on the risk assessment and treatment when necessary

-Promoting breastfeeding (8-12 times/day)
-Discourage the use of routine water or dextrose water supplementation
-In a healthy newborn (>35 weeks), treatment course is determined by physical findings, bilirubin level according to age and risk designation
-Phototherapy
-Rebound bilirubin testing (not required in full-term newborns with physiologic jaundice)

-Indirect bilirubin
-Contraindicated in elevated direct bilirubin

-TSB levels of 2 to 3 mg/dL
-Newborns without risk factors

-Dressed in only a diaper
-Temperature monitoring
-Increased fluid intake
-Avoid oral drugs due to decreased absorption

-Bililights
-Biliblanket (fiberoptic pad)
-Bilibed

-Overhead lights placed close to the newborn
-Requires eyepatches (remove at intervals to prevent corneal abrasion)

-Fiberoptic pad
-Allows ongoing interaction between mother and newborn
-Pad is placed under clothing

Bed with lights and baby is lying on back

-Sudden unexpected death in infants
-Suffication
-Asphyxia
-Entrapment
-Infection
-Ingestions
-Metabolic disease
-Trauma

-Subcategory of SUIDs
-Infant deaths that are unexplained after a thorough case investigation including autopsy, a scene investigation and clinical history

-Sleep in the same room but not same bed for 6 months
-Pacifiers
-Parental avoidance of illicit drugs, alcohol and smoking
-Supine position
-Avoiding bumper pads

-Before 6 months
-Peak between 1 and 4 months

-Brief, resolved, unexplained events
-Occurs in infants less than 1 year od age
-Witnessed brief event where the child returns to baseline and has a normal history and physical examination
-<1 minute but usually <20 to 30 seconds

-Decreased arousal
-Asphyxia
-Rebreathing
-Thermal stress

-Previous BRUE
-Poverty
-Lack of prenatal care
-Low birth weight
-SGA
-Preterm birth
-Young maternal age
-High parity
-Maternal smoking and drug use
-Co-sleeping
-Restrictive clothing
-Hyperthermia
-Respiratory obstruction

-No signs of injury (nonaccidental trauma must be ruled out)
-Frothy blood tinged secretions in mouth and nares
-Intrathoracic petechiae on autopsy
-Retention of periadrenal brown fat on autopsy

-Obtain a thourough history
-Reassure family it was not their fault
-Offer support and counsel to the family
-Supply names of support groups
-Provide follow-up for at least 1 year
-Assist surviving siblings
-The use of home monitoring has not been shown to reduce SIDS (their use is discouraged)

-Note size, shape, symmetry and general appearance
-Look for signs of trauma (forceps hematomas)
-Palpate sutures (normal for some overriding)
-Palpate fontanels (VERY IMPORTANT) (check location, number and size)
-Note normal and abdnormal deviations
-Head is usually 2cm larger than chest diameter (catches up at 1 year old)

-Junction of sagittal & coronal suture
-Diamond-shaped 1-4cm
-Closes at 9-18 months
-Pulsates

-Junction of lambdoidal & sagittal sutures
-Triangular, fingertip
-Closes by 3 months of age
-Can be normal not to palpate at birth because of molding

CONCERNING
-Between anterior & posterior fontanels along sagittal suture
-Varies in size
-May be associated with congenital anomalies

-Larger fontanels can be seen in hypothyroidism
-Bulging, full, or tense fontanel may be associated with increased ICP from hydrocephalus, birth injury, bleeding, or infection

CONCERNING
-FOC less than 2 standard deviations below the mean for age and gender
-FOC <3rd percentile for gestational age
-Indicator of failure of brain development
-Delayed developmental milestones-not able to detect at birth
-Treatment supportive-geared toward management of deficits
-Refer to neurology for diagnosis

-FOC greater than 2 standard deviations above the mean for age and gender
-Can be associated with pediatric chromosomal and developmental conditions

-Excess CSF in ventricles of brain due to a decrease in reabsorption or overproduction
-Rapidly increasing FOC
-Causes: tumor, hemorrhage, infection, congenital malformation

-Full and bulging fontanels
-Large head with widened sutures
-Irritability
-Vomiting
-Anorexia

-Head can expand due to no sutures
-But if head is swelled to the point of vomiting then it is concerning

-Cause of external cranial swelling
-Represents venous bleeding between the aponeurosis and ther periosteum
-Can increase in size over the first hours to days of life
-Associated with mechanically assisted deliveries, due to external shearing forces

-Large boggy, shifting collection of fluid
-Extends over cranial surface to neck and behind ears
-Hypovolemia if the fluid develops quickly and is large
-Hyperbilirubinema

-Adolescents
-Typically approximated and not fully fused as a newborn
-Allows overlapping during a vaginal delivery

-After vaginal delivery, most neonates have some molding
-Result of pressure exerted during the birth process
-More pronounced in 1st-born babies & those engaged for an extended period of time
-Overriding suture lines
-Suture lines should be displaceable
-Distortion usually disappears within 1-5 days after birth
-Failure of normal expansion can indicate microcephaly or craniostenosis

NORMAL
-Scalp edema caused by pressure during delivery
-Resolves within 5-7 days
-Parental reassurance

Crosses suture lines
-Parietal regions of the scalp
-Immediately seen at birth
-May have pitting edema
-Does NOT increase in size after birth

-No treatment necessary
-Monitor for jaundice if there is bruising

NORMAL
-Deep collection of blood in the subperiosteal area of the scalp
-From a traumatic delivery
-Resolution may take months

-May not be present at birth, but appear within 24 hours
Does NOT cross suture lines
-Usually unilateral, may be bilateral
-15-20% associated with fractured skull

-No treatment
-Calcification of the hematoma can occur: bony prominence may require months to resolve
-Monitor for jaundice

NORMAL
-Thinning of skull bones
-Ping-pong ball sensation when examiner presses scalp, usually parietal bone
-Differentiate between softness along suture lines
-Higher incidence with prematurity
-If multiple areas, may indicate syphilis or calcium deficiency: Becomes concerning at this point
-Look for hydrocephalus

CONCERNING
-Premature fusion of skull sutures
-Look for absent fontanels
-Normal brain growth inhibited
-Usually develops in utero
-20% associated with genetic syndrome
-Surgery usually performed at 4-7 months
-Refer to neuro

-The result of brain growth
-Absence of, more than 2, or abnormal placement may indicate abnormal brain growth/development

-Observe symmetry, spacing, & size
-Assess PERRLA
-Tears may not be produced until 2 months of age
-Iris is dark until 3-6 months of age when eye color may change, can change as late as 12 months
-Uncoordinated eye movements are common until 3-4 months
-Red reflex indicates intact lens and no retinoblastoma
-Can see 8-12 inches after unmedicated delivery
-Do NOT try to force eyes open-hold infant under arms & gently sway or turn

NORMAL
-Result of pressure on fetal head during delivery
-Will usually resolve within 10 days
-No pathological significance even when extensive

CONCERNING
-Abnormal pupillary reflex
-Usually a history of maternal prenatal infection, drug exposure, or hypocalcemia
-Treatment is surgical removal of the lens
-Outcome depends on type of cataract

Narrow eye set

Wide set eyes

-Observe symmetry
-Observe auricle development
-Measure eye to ear alignment
-Palpate cartilage
-Assess ear recoil
-Visualization of ear drums usually impossible-check patency of ear canals
-Newborn hearing screen mandated by law in TX
-Blinks in response to loud noise

NORMAL
-More reassuring if ear structure is normal
-May be associated with renal anomaly
-Renal ultrasound NOT routinely recommended unless multi-system concern

CONCERNING
-May be associated with:
Renal anomolies
Chromosomal anomolies
Congenital anomolies

-Result from imperfect fusion of the tubercles of the first and second branchial arches during gestational development
-Familial
-More common in females
-Commonly associated with ear and face anomolies as well as hearing loss
-Need to confirm newborn hearing evaluation

-Come in before the first month of life
-Usually lower incisors
-Removal recommended because usually loose & pose risk of aspiration (not always indicated)
-Refer to pedi dentist
-No root system associated

-Oral counterpart of facial milia
-Occurs on midline of palate or alveolar ridges
~60% of neonates
-“Shed” within a few weeks

-Small, circumscribed, compressible lesion of the oral mucosa
-Thought to be the result of trauma which leads to rupture of salivary glands
-May rupture and discharge for several months
-Observe for signs of infection

-May be observed unilaterally or bilaterally
-If unilateral it is usually on the left side
-Bilateral cleft lip is usually associated with cleft palate

-Tongue-tied
-When the sublingual frenulum is attached to the anterior portion or tip of the tongue

-Asymmetrical shortening of the sternocleidomastoid muscle that results in preferential turning of the head to one side
-Limitation of full range of motion or a head tilt
-Refer for physical therapy

-Associated with:
Turner’s Syndrome
Noonan’s
Down Syndrome

-Asymptomatic: detected as a lump over clavicle 7-10 days following delivery
-Symptomatic: Exam reveals decreased or absent movement of arm, discoloration over fracture site, crepitus, tenderness, irregularity along clavicle
-Don't brace, just handle the baby gentle

CONCERNING
-Trauma causes hemorrhage & edema into nerve sheath
-Usually presents 1st 2 days after birth
-Usually does not improve, but does not increase in severity

-Persistently open eye on affected side
-Suck with drooling
-Mouth drawn to normal side during crying

-Result of oligohydramnios in utero
-Lack of normal kidneys-leads to inadequate production of amniotic fluid
-Associated with: CV, neuro, GI, MSK, & genetic anomalies

-Flattened facies
-Malformed ears
-Contraction deformity of limbs

-Stretch or traction injury
-80% Erb’s Palsy:
C5-C6: shoulder & arm
-Klumpke:
C8-T1, wrist & hand
-Refer to ortho, treatment with PT & splints
-Will have some degree of disability in life

-Limp hand and wrist
-Absent grasp reflex
-Moro reflex absent or incomplete on affected side

-Varies from skin tag to extra formed finger
-1:300 Black
-1:3000 White
-Possible surgical removal when infant is older
-Removed for cosmetic reasons

-Fingers fused by skin & sometimes bone
-1:2200 live births
-Surgical separation deferred 3-5 years

-Barlow Maneuver: adducting the hip and dislocating
-Ortolani Maneuver: reducing the dislocation by abducting the hip creating a "click"

-First 2 days of life 15-60ml/24hr
-3-10 days of life 100-300ml/24hr

-24-48 hours
-Concerned if longer because it could indicate a meconium ileus

CONCERNING
Defect in the abdominal wall to the right of the umbilical cord with the intestinal contents herniated through this defect, unprotected by a sac
-Apply protective gauze with cellophane to maintain warmth
-1:10-20,000 births

CONCERNING
-Herniation of abdominal viscera into the umbilical cord with the umbilical arteries & veins inserting into the apex of the defect
-1:5000 births
-EMERGENCY-immediate surgical repair is indicated to prevent drying if sac has ruptured

-Weakness or imperfect closure of the umbilical ring
-Avoid taping coins & belly bands-contributes to infection and incarceration
-Give AG about observation for incarceration
-Surgical referral only necessary for incarceration or if persists >5-7 years

CONCERNING
-Lack of rectal opening
-Endoscopic exam & ultrasound to indicate degree of malformation
-Immediate surgical repair with or without colostomy

-Infant should be held in prone position with head in midline
-Check end of coccyx for pilonidal sinus or dimple
-Hair tuft means probable connection to the spinal canal
-Check with sacral ultrasound

CONCERNING
-Neural tube defect
-75% cases occur in lumbosacral regions
-Mortality 10-15%
-70% normal intelligence

-Absence of DTR
-Flaccid paralysis of lower extremities
-Lack of response to touch & pain
-Constant urinary dribbling

If you can see in the bottom of that dimple, you need an ultrasound to make sure that there is no connection to the spinal canal

-Observe symmetry of movement
-Auscultate lungs
Respiration rate & rhythm
-Auscultate heart
Note location & intensity of PMI (normally at LSB 3rd-4th ICS)
Assess rate while infant is quiet
Assess capillary refill
Palpate femoral & brachial pulses
-Murmurs are noted for loudness, quality, location, & timing

NORMAL
-Usually appears by day 3 of life
-Can appear after 1-2 weeks
-May discharge a milk-like substance (witch’s milk)
-Usually disappears by one month
-Due to withdrawal from maternal hormones
-Not normal later in life (infancy)

-Inverted sternum
-Only concerning if there is compression on the heart and lungs

-Protruding sternum
-Associated with marfan syndrome and congenital heart disease

More than 2 nipples

-Autosomal-dominant
-Connective tissue disorder
-Cystic medial necrosis of aorta
-Joint laxity
-Subluxation of ocular lens
-Arm span exceeds height

-Vaginal skin tags-hypertrophied tissue
-Ecchymosis & edema of labia common in breech deliveries
-Observe for patency of vaginal opening
-Hypertrophy of labia minora has no clinical significance-usually related to gestational age
-Fingertip space between vagina & anus in term infants
-Normal vaginal discharge-white &/or bloody starting 2-3 days after birth

-Normal length of penis is 3.1-3.9cm from pubic bone to tip of glans
-Recent circumcised penis should be inspected for bleeding, incision site infection, & edema
-Micropenis: (>2sd below mean length or width for age using standard charts) associated with neonatal hypoglycemia, cryptorchidism, persistent jaundice, or cleft lip/palate strongly suggests hypopituitarism

-Hypertrophy of clitoris
-Palpable gonad
-Anterior displacement of urinary meatus
-Inseparably fused labia
-Abnormal openings or dimplings on perineum
-Decreased spacing between vagina & anus
-2 or more findings increase probability of gender ambiguity

CONCERNING
-Urethral meatus appears anywhere between the ventral glans & perineum
-NEVER do circumcision: extra skin is used during repair
-Surgery is usually done between 12-36 months, depending on severity

Curvature of penis

CONCERNING
-Displacement of intestines into scrotal sac
-Nontransilluminating
-May auscultate bowel sounds
-Sometimes reducible
-Surgical consult indicated

CONCERNING
-Twisting of testis on its spermatic cord
-Can occur in utero
-Usually unilateral
-Presents with nontender or mildly tender, mass with reddish to bluish coloring of scrotal skin
-No transillumination
-Surgical emergency

-Fluid collection in testicular sac
-Transilluminates (bright red)
-Non-tender
-Can be transient
-Unilateral or bilateral
-Usually resolves by 12 months

-One or both testes not completely descended into scrotal sac
-Inguinal hernias common
-Risk of infertility & malignancy if untreated
-Orchiopexy at 1-2 yrs

-Observe:
Posture
Square window test
Arm recoil
Popliteal angle
Scarf sign
Heal to ear

-“Startle Reflex”
-Extension & abduction of arms followed by flexion & adduction
-May or may not cry
-Incomplete at 28 weeks
-Complete by 37 weeks
-Gone by 3-6 months

-Palmar Grasp
-Fingers close immediately when object placed in hand
-Starts at 28 weeks
-Gone by 2 months

-Hold infant upright & touch foot to flat surface
-Ranges from minimal weight-bearing to several brisk steps with plantar stimulation
-Present at 37 weeks
-Gone by 2-4 months

-Baby automatically sucks when soft palate, lip, mouth, cheek, or chin is stimulated
-Survival reflex
-Gone by 4-6 months

-When cheek is stroked, baby will turn in direction of stimulus, mouth open & ready to suckle
-Gone by 4 months

-80-180 beats/min
-70-80 during sleep
-120-160 awake

30-60 breaths/min

-Systolic: 57-69
-Diastolic: 44-52

-No ongoing issues
-Term
-Stable vital signs for 12 hours before discharge (Temp: 97.7-99.3, HR: 100-190, RR: <60)
-Passage of urine and at least one stool
-2 successful feedings
-Normal physical exam
-Vitamin K administration and no signs of bleeding
-Baseline bilirubin and no signs of jaundice
-Evaluation and monitoring for sepsis
-Newborn lab data completed

-Hep B administered
-Mother has received tetanus toxoid, reduced diphtheria, pertussis and influenza
-Social support identified
-Social situation adequate
-Appropriate medical home identified with follow up care planned
-Mother knowledgeable in the care of the newborn

-Adverse Childhood Experiences
-Dose related response

1. Physical abuse
2. Emotional abuse
3. Sexual abuse
4. Physical neglect
5. Emotional neglect
6. Caregiver mental illness
7. Caregiver separation
8. Maternal abuse
9. Incarceration of a caregiver
10. Substance abuse by a caregiver

-Cardiovascular disease
-Autoimmune conditions
-Chronic lung illnesses
-Headaches
-Obesity
-Smoking
-Generalized poor health
-Early death
-Cancer
-Diabetes
-SIDs

-Hyperactivation of the amygdala
-Loss of neural connections in the hippocampus
-Overactivity of the orbitofronal cortex
-Impared critical thinking capabilities

-Depression
-Anxiety
-ADHD
-Austism
-Binge exploiting behaviors
-PTSD
-Increased risk taking
-Violent behaviors
-Suicide attempts
-Drug and alcoholism

1. Positive
2. Tolerable
3. Toxic

Accumulation of toxic stress then leads to physical and psychological abnormalities due to maladaption of the stress cascade system

-Necessary and important for development
-Stimulates fight or flight
-Trains their bodies to self-adjust through negative feedback systems
-Short-lived

-Unavoidable circumstances where allostatic load is increased and altered over a slightly longer period of time
-As long as there is positive supportive relationships, stress does not alter brain development

-Occurs when there is not supportive relationship with tolerable stress
-Occurs when there is prolonged allostatic load, leading to an imabalance of the NEI system and causing a surge of the sympathetic nervous system
-Fight or flight all the time
-Negative health outcomes

-Dysregulation of hormones
-Constant release of:
Epinephrine
Norepinephrine
Cortisol (fat build up, immune system dysregulation, and weight gain)
Increased cytokine response

-Gains 5-7 ounces weekly during the first 6 months
-By 6 months, weight doubles
-By 1 year, weight triples

-Leading causes:
Congenital malformations
Low birth weight
Prematurity
Maternal delivery complications
Sudden infant death syndrome (SIDS)
Unintentional injuries
-Of these five leading causes, four declined, but deaths due to unintentional injuries increased by 11%.
-Highest incidence in Non-Hispanic African Americans

-Primary care levels
Primary care: is generalist care
Secondary care: requires specialized expertise
Tertiary care: requires both specialized expertise and equipment
Quaternary care: requires highly specialized expertise and highly unusual or specialized equipment
-More person than disease centered care
-Primary interface between the child/family and the health system
-Emphasis is on health promotion and protection, disease and/or/disability prevention
-First contact point

-Healthy development
-Family support
-Mental health and emotional well-being
-Nutritional health
-Physical activity
-Healthy weight

-Promoting lifelong health for families and communities
-Oral health
-Healthy adolescent development
-Safety and injury prevention
-Promoting the healthy and safe use of social media
-Children and youth with special health needs

-Efforts that keep disease processes from becoming established
-Health Promotion
-Specific Protection

-Early diagnosis and prompt treatment
-Efforts that interrupt the disease process

-Limit the physical and social consequences of symptomatic disease
-Improve survival and/or quality of life
-Disability limitation and 2) rehabilitation

-Gains 5-7oz per week for the first 6 months
-Grows 1cm per month for the first 6 months
-Primitive reflexes present
-Obligate nose breather

-Turns head from side to side when prone
-Lifts head briefly when prone
-Marked head lag
-Hips are downward and limp when held standing

-Hands mostly closed with non-directional hand swipes
-Strong grasp reflex
-Clenches when in contact with rattle, necklace and hair

-Shows anger, sadness and joy
-Makes sound while eating

-Fixates eyes on object
-Quiets to voices

-Intently watches faces when talked to
-Fixes on colors
-Calms when spoken to

-Posterior fontanel closes
-Crawling reflex disappears

-Decreasing head lag
-Lifts head and chest while prone
-Holds head upright but forward whle sitting

-Hands frequently open
-Fading grasp reflex

-Vocalizes more than crying
-Coos vocalizes to familiar voice

-Follows toy side to side when supine
-Searches for sounds
-Turns head to sounds

-Has social smile
-More awake during the day

All primitive reflexes fading

-Holds head erect when sitting but bobs
-Body symmetric when prone
-Begins to bear weight when standing

-Holds rattle, but will not reach for it
-Absent grasp reflex
-Hands kept loosely open
-Pulls at blankets and clothes

-Squeals to show pleasure
-Coos
-Begins babblings
-Vocalization when smiling and spoken to

-Looks at mirrors, pictures of faces, shaoes and colors
-Follows object 180 degrees
-Turns head to locate sound

-Shows interest in surroundings
-Stops crying when parents enter the room
-Recognize familiar objects and faces
-Begins to be aware of strange stimuli or situations

-Begins drooling
-Moro and tonic neck reflexes disappeared

-Begins to roll prone to supine
-No head lag when pulled to sit
-Balances head well in sitting position
-Sits upright if propped

-Plays with own hands
-Reaches for items
-Grasps rattle, but cannot pick it up
-Mouths most objects

-Vocalizations show mood
-Laugh out loud
-Make b, g, h, n, and p sounds

-Begins eye-hand control
-Focuses on objects farther away from face (0.5in)

-Enjoys interacting with others
-Fusses for attention
-Anticipates feedings when sees bottle or mother
-Prefers certain toys

-Birth weight doubles by the end of the month

-Rolls supine to prone
-Inserts toes to mouth when supine
-Sits well with support

-Uses palmar geap to pull objects to mouth
-Holds one cube
-Plays with toes

-Squeals in delight
-Begins to coo
-Vocalizes anger when objects taken away

-Visually follows dropped objects
-Localizes sound made below ear

-Recognizes family members
-Smiles at mirror image
-Pats bottle or breast with hands
-Rapid mood swings
-Discovers body parts
-Plays enthusiastically

-Birth weight doubles
-Growth rate declines (3-5 ounces/week)
-Height increased
-Chewing and biting begins

-Rolls from supine to prone
-Sits in high chair with back straight
-Bears weight on legs when supported

-Grasps and manipulates small objects
-Bang small objects
-Releases one object when offered another
-Grasps feet and pulls to mouth
-Holds bottle if bottle feeding

-Begins to initiate sounds
-Has 1 syllale utterances
-Vocalizes to toys and mirror image
-Face brightens to own sounds

-Adjusts posture to see an object
-Localizes sound made above ear

-Recognizes parents
-Fears strangers
-Extends arms to be picked up
-Imitates sticking out tongue or coughing
-Definite likes and dislikes
-Searches briefly for dropped objects

-Lifts head off surface when supine
-Sits erect momentarily then leans forward to tripop position
-Bounces when held standing

-Grasps witb one hand
-Holds 2 objects
-Bangs objects on table
-Transfers objects from one hand to the other
-Rakes objects

-Vocalizes four distinct vowels
-Combines vowel sounds wtih constantants to produce syllables without meaning (baba and dada)

-Respons to own name
-Turns head to localize sound
-Has definite taste preferences
-Gaze fixates on small objects

-Imitates simple acts and noises
-Attracts attention by coughing or snorting
-Increasing stranger anciety
-Worries when parent disappears from sight
-Plays peek-a-boo
-Refuses foods by keeping lips closed
-Bites with frustration

-Starts regular bladder and bowel patterns
-Parachute reflex emerges (extending arms to break a fall)

-Sits steadily unsupported for short periods of time
-May stand holding onto furniture
-Adjusts position to reach an object

-Develops pincer grasp
-Begins the dropping game
-Shakes rattle to
-Holds 2 cubes while looking at a third
-Reaches for out of reach objects

-Listens subjectively to familiar words
-Consonant sounds including t and w
-Begins to have vocalizations with emphasis on emotion

-Increased anxiety when paren is unseen
-Increased stranger anxiety
-Understands the word "no"
-Dislikes dressing or diaper change

Pincer grasp refines

-Steadily sits for up to 10 minutes
-Pulls to stand when holds onto furniture
-Crawls

-Hand dominance emerges
-Refines pincer grasp
-Compares cubes by bringing them together
-Grasps a third cube

-Comprehends "no"
-Responds to simple verbal commands

Localizes sound by turning head